Download Hypertrophic Cardiomyopathy

Venice, 18 October 2015
Long term outcome of AF ablation in different
clinical settings:
Hypertrophic Cardiomyopathy
Andrea Corrado, MD
UOSD Cardiac Pacing & Electrophysiology
Cardiovascular Department
"Dell’Angelo" Hospital of Mestre, Venice
NO CONFLICT OF
INTEREST TO
DECLARE
Prevalence of AF in HCM
!  The prevalence of atrial fibrillation in hypertrophic
cardiomyopathy patients is high
range 18%–22%
!  It may be related to atrial dilation and atrial fibrosis, in
the setting of remodeling for diastolic dysfunction and
mitral regurgitation
2014 ESC Guidelines on diagnosis and
management of hypertrophic cardiomyopathy
Effects of AF in HCM
!  AF it is often poorly tolerated by HCM patients
because of loss of atrial contraction and reduced
filling time with rapid ventricular rates.
!  AF is associated with increased morbidity and
mortality from heart failure and stroke
2014 ESC Guidelines on diagnosis and
management of hypertrophic cardiomyopathy
Incidence of TE for AF in HCM
!  annual incidence of thromboembolism (stroke and
peripheral embolism) in patients with AF were
3.8%
2014 ESC Guidelines on diagnosis and
management of hypertrophic cardiomyopathy
OAT for AF in HCM
!  patients with HCM have not been included in
clinical trials, use of the CHADS-VASC score risk
is not recommended
!  it is recommended that all patients with AF should
receive OAT lifelong
2014 ESC Guidelines on diagnosis and
management of hypertrophic cardiomyopathy
Diagnosis of AF in HCM
48-hour ambulatory ECG monitoring
every 6–12 months to detect AF
should be considered in patients
who are in sinus rhythm and have
an LA diameter of ≥ 45 mm
IIa
2014 ESC Guidelines on diagnosis and
management of hypertrophic cardiomyopathy
Major clinical features associated with risk of SCD
!  Age
!  NSVT
!  LV wall thickness
!  Family history of SCD
!  Syncope
!  LA diameter
!  Left ventricolat outflow tract obstruction
!  Exercse blood pressure response
2014 ESC Guidelines on diagnosis and
management of hypertrophic cardiomyopathy
Therapy of AF in HCM
!  Current guidelines for management of AF
recommend a rhythm control strategy in HCM
patients
2014 ESC Guidelines on diagnosis and
management of hypertrophic cardiomyopathy
AADs for the managment of AF in HCM
!  Antiarrhythmic drugs are often used despite minimal
evidence
2014 ESC Guidelines on diagnosis and
management of hypertrophic cardiomyopathy
AADs for the managment of AF in HCM
Amiodarone should be considered
for achieving rhythm control and to
maintain sinus rhythm after
cardioversion
IIa
2014 ESC Guidelines on diagnosis and
management of hypertrophic cardiomyopathy
RF ablation for the managment of AF in HCM
Catheter ablation for atrial
fibrillation should be considered
in patients without severe left
atrial enlargement, who have
drug refractory symptoms
IIa
2014 ESC Guidelines on diagnosis and
management of hypertrophic cardiomyopathy
Catheter ablation for atrial fibrillation in
hypertrophic cardiomyopathy patients:
a systematic review
Ha, HSK et al
J Interv Card Electrophysiol. 2015 Nov;44(2):161-70 (Epub 2015 Aug 25)
!  8 studies
!  241 HCM pts underwent AF ablation
Results (241 pts)
Number
of patients
Prevalence Maintenance
of SR (%)
of AADs (%)
Hayashi
2014
17
82
47
Santangeli
2013
43
53
76
Derejko
2013
30
53
37
Di Donna
2010
61
67
36
Bunch
2008
33
47
48
Gaita
2007
36
64
23
Kilicaslan
2006
27
70
22
Liu
2005
4
75
23
Results (241 pts)
!  The mean follow up 18-19 months
!  Efficacy in paroxysmal AF:
71 %
!  Efficacy in nonparoxysmal AF: 59 %
!  Redo procedures:
43 %
!  Pts still requiring AADs:
25 – 36 %
Outcomes of non pharmacologic treatment of
atrial fibrillation in patients with hypertrophic
cardiomyopathy
Bassiouny M, et al
Heart Rhythm 2015;12:1438–1447
!  147 HCM pts underwent AF ablation
!  79 catheter ablation
!  68 surgical ablation
!  Follow up 36 months
Results (after first ablation)
81%
74%
51%
58%
43%
29%
Results (major complications)
!  Major complications:
!  Catheter group 6%
2 PVI stenosis - stent, 1 tamponade,
1 stroke, 1 goin hematoma - transfusion
!  Surgical group 18%
3 died (1 sepsis, 1 heparin induced
thrombocytopenia, 1 at home - unknown)
3 tamponade, 1 stroke, 1 SVT pulseless,
1 complete AVB, 1 pulmonary embolism,
1 severe mitral regurgitation, 1 pericarditis
Results
!  On last FU, patients reported symptomatic improvement
with decrease in NYHA functional class (from 2.55
to1.14 ).
!  NYHA class improved in both patients who had a
successful PVI as well as in those who had recurrent
arrhythmia. AF became better controlled with decrease
in prevalence of persistent AF.
Results (predictors of success)
!  Male
!  Higher baseline EF
!  Paroxismal AF
!  Short of AF duration
!  Lower stage of diastolic dysfunction
Impact of Left Ventricular Diastolic Dysfunction on
Outcome of Catheter Ablation for Atrial Fibrillation in
Patients With Hypertrophic Cardiomyopathy
Okamatsu H, et al
Circ J. 2015;79(2):419-24
!  22 HCM pts underwent AF ablation
!  Median follow up 21 months
!  Sinus rhythm was maintained in 59% of patients
!  LV diastolic dysfunction was associated with difficulty of
rhythm control after ablation
Results
Atrial fibrillation ablation in patients with
hypertrophic cardiomyopathy long-term
outcomes and clinical predictors
Contreras-Valdes, FM, et al
JACC 2015;65:1984–94
!  40 HCM pts underwent AF ablation
!  64 pts underwent AF ablation without HCM but similar
AF characteristics
!  Median follow up 54 months
Results
Conclusions
!  efficacy of AF ablation in HCM patients is
significantly lower compared with non affected
patients
!  independent predictors of arrhythmia recurrence:
!  higher LV outflow obstruction
!  higher baseline left atrial pressure
!  higher dilatation of left atrium
QTc Interval Prolongation Predicts Arrhythmia Recurrence
After Catheter Ablation of Atrial Fibrillation in Patients
With Hypertrophic Cardiomyopathy
Wen SN, et al
Circ J 2015; 79: 1024 – 1030
!  39 HCM pts underwent AF ablation
!  follow up 15 months
!  Efficacy 41% of patients
!  QTc prolongation resulted to be an independent
predictor of arrhythmia recurrence
Results
Left atrial wall thickness and outcomes of catheter
ablation for atrial fibrillation in patients with hypertrophic
cardiomyopathy
Hayashi H, et al
J Interv Card Electrophysiol. 2014 Aug;40 (2):153-60
!  17 HCM patients vs 34 control patients without heart disease
!  age, gender, type of AF, and LA dimension were matched
!  the LA wall in the HCM patients was not thicker than that of the
matched patients without structural heart disease
!  efficacy did not differ between the two groups (53 vs. 56 %)
AF ablation in HCM: yes or not?
!  Worse results in term
of mantainig SR
"  large atrium
"  dystolic disfunction
"  atrial fibrosis
AF ablation in HCM: yes or not?
!  Worse results in term
of mantainig SR
"  large atrium
"  atrial fibrosis
!  Better results in terms
of QoL
"  pts very
symptomatic
"  AADs poorly
efficacy
AF ablation in HCM: when?
! Early procedure
! Shorter hystory of AF
! Atrium less then 45 mm
! Less degree of dystolic dysfunction
Venice, 18 October 2015
Thank you for attention